ISBAR: Adding an extra step in handoff communication

While examining its incident reports, Hartford (CT) Hospital noticed many accidents resulted from a lack of communication during patient handoffs. Adding an “I” was the answer to invoking some chatter.

“We decided to add ‘I’ [in front of SBAR] because we thought it was very important that the clinicians start off with an introduction if they didn’t actively know the person they were speaking with [during a patient handoff or over the phone],” says Ruth Brunner Zafian, MSN, MA, APRN-BC, clinical nurse specialist in cardiovascular services at the hospital.

The thorough examination of incident reports prompted the housewide healthcare team, a multidisciplinary committee, to look at The Joint Commission’s requirements for a standardized method of communication under Goal #2E.

The first step was to conduct literature searches on patient handoffs. During the literature search, “SBAR seemed to have the most press, it had a good safety record already, and it seemed to closely mimic what we felt most experienced healthcare providers were already doing [at the hospital],” Zafian says.

SBAR (i.e., situation, background, assessment, recommendation) is a tool developed by Michael Leonard, MD, along with colleagues at Kaiser Permanente of Colorado, that is designed to streamline the way doctors and nurses communicate during telephone calls and patient handoffs.

Hartford added the “I” for introduction and required all licensed employees involved with direct patient care to follow the new communication protocol daily. (See “ISBAR in action” below for more information.)

Educate with yellow

Yellow is the staple color for ISBAR educational material at Hartford. “We want everyone here to think ISBAR every time they see the bright yellow,” Zafian says.

The facility uses the following educational materials:

Posters and flyers on every nursing unit stating what ISBAR is

Laminated pocket cards detailing when and how to use ISBAR

Pads of paper for staff members to organize their thoughts before making a patient report or phone call

The ISBAR initiative created a change in direct care providers’ practice. Some staff members jumped on board, and others felt it was just the flavor of the month, Zafian says. To help the staff transition into this new change in patient care, physician champions were assigned.

Zafian and Jansky recruited these champions to educate staff members on ISBAR by speaking individually with them regarding the program. The champions received an ISBAR laminated pocket card to discuss the program with other Hartford physicians individually and during division meetings.

The education worked quickly. One physician champion even came into Zafian’s office and asked for more laminated cards. “A few minutes later, he was outside my office talking to three different physicians about the program enthusiastically,” Zafian says.

Rise in communication

Zafian says she wanted to determine the effectiveness of ISBAR during patient handoffs and phone conversations with physicians. Along with a group of senior nursing students from a local college, she conducted a research project and surveyed staff members.

The research project revealed that direct care providers use ISBAR approximately 71% of the time during patient handoffs and phone conversations with physicians.

The project also measured whether the staff member receiving the ISBAR report was able to repeat at least 50% of the message regarding the patient—“a so-called meeting of the minds,” says Zafian. If staff members could list at least 50% of the topics identified by the person giving the report, then there was a “meeting of the minds.”

“When we cross-referenced this information with who did and did not use the ISBAR report, we found that when ISBAR was used, there was a meeting of the minds 58% of the time,” Zafian says. “And when ISBAR was not used, there was a meeting of the minds only 23% of the time.”

Staff members were much happier with the change. “ISBAR is a great handoff report because it improves communication among staff and provides pertinent information about a patient,” says Julie Masamery, RN, clinical nurse leader in general surgery. “Once you learn the format, it’s like second nature.”

They were prepared to show surveyors a three-ring binder that detailed the success of ISBAR around the hospital.

But the surveyors didn’t ask to speak to Zafian or Jansky or view their binder because they consistently heard about ISBAR from staff members as Hartford’s standardized method of communication.

“[The Joint Commission was] satisfied that everywhere they went, they heard ISBAR from staff,” Zafian says. “You have to keep talking about ISBAR to staff, and you yourself have to be a champion on the program so it doesn’t get forgotten about [in daily professional practice].”

ISBAR in action

Introduction

Introduce yourself and your role in the patient’s care

State the unit you are calling from when speaking with a physician over the phone

Situation

Specify the patient’s name and current condition or situation

Explain what has happened to trigger this conversation

Background

State the admission date of the patient, his or her diagnosis, and pertinent medical history

Give a brief synopsis of what’s been done so far (e.g., lab test)

Assessment

Give a summary of the patient’s condition or situation

Explain what you think the problem is or say, “I’m not sure what the problem is, but the patient is deteriorating”

Expand upon your statement with specific signs and symptoms

Recommendation

Explain what you would like to see done (e.g., lab tests, treatments, or “I need you to see the patient now”)

State any new treatments or changes ordered (e.g., monitoring and frequency or when to renotify the physician if there is no improvement in the patient)